Claim reviews are an essential task in the world of property and casualty insurance. However, in an era marked by rapidly evolving risks and advancing technologies, the claim review process has not evolved much over time. Most claim reviews today bear a striking resemblance to those conducted in the 1990s or even the 1980s.
Before a single review takes place, the claims professional has much to do, including a line-by-line audit of each claim in the client's caseload. This labor-intensive process creates capacity constraints on adjusters, who already have an assigned caseload with claims to investigate, evaluate and resolve. The preparation for these claim reviews can take many hours and even days. It is typical for an experienced adjuster to prepare for and attend multiple claim reviews each month. It is common for brokers, MGAs, policyholders, self-insureds and carriers to request monthly, quarterly, annual and even some ad hoc claim reviews.
The insurers want to stay informed on new claims, pending claims, reopened claims, claim financials, emerging risks, litigation involvement and any other insights into their risks/book of business and obtain a deeper understanding about the cause of loss on the individual claims. Each claim is discussed in detail to assess if the claim is compensable, if the insured has committed negligence, if there is the potential for a nuclear verdict or if there is an affirmative defense in that venue. The alleged injuries/damages of the claim are reviewed along with the claim timeline to develop an agreed-upon approach to resolve the claim in good faith. For many years, the burden of preparing for the claim reviews has rested primarily with the claims professionals. Claim reviews are and will remain part of the claims ecosystem.
See also: AI's Role in Modern Claims Management
Is There a Better Way?
Yes, artificial intelligence can dramatically improve and speed up the process of claim review preparation. Claims organizations can benefit from AI by choosing tools designed to remove friction and simplify processes.
While general-purpose AI tools like ChatGPT, Gemini or even earlier versions of Siri have gained widespread recognition, finding the right fit for your industry and profession is essential. Many of today's more advanced AI tools are not trained on insurance claims data, nor are they designed to generate intelligence that would be helpful in a claim review.
Document Intelligence for the Modern Claim Review
Advanced document intelligence tools are revolutionizing the claim review process. These cutting-edge solutions augment the traditional approach by visually organizing and presenting comprehensive claim summaries, risk trends and insights, claim financials and treatment timelines with both the structured claim data and claim documents. The goal of document intelligence is to provide a tailored, trained knowledge base, which is then used to inform the claims professional and augment manual tasks like claim reviews.
Using document intelligence to understand claims documents is helpful, but is it what you really need? The most effective solutions are those trained specifically on claims data, enabling them to provide nuanced insights and support that align closely with the needs of insurance professionals. The ideal tool is one trained in claims data that synthesizes the art (decision-making) and science (data) of what you do. This combination of specialized knowledge and advanced analytics capabilities creates a powerful tool that enhances human expertise rather than attempting to replace it. That's what we call augmented intelligence.
As first published in Insurance Innovation Reporter.
